Faculty Bibliography

INTRODUCTION/BACKGROUND:Surgeons can improve their practice by understanding potentially avoidable reasons for early revision total knee arthroplasty (rTKA). The purpose of this study is to describe potentially avoidable indications for rTKA within 5 years of the index procedure. METHODS:This retrospective observational analysis utilized the rTKA database at a large, academic orthopedic specialty hospital to identify 167 consecutive rTKA from 2014 to 2019 performed within 5 years after primary TKA (pTKA). Two fellowship-trained arthroplasty surgeons reviewed the cases to classify them as potentially avoidable or unavoidable. Unavoidable indications for rTKA included infection/wound complication, arthrofibrosis, instability due to underlying collagen disease or significant weight loss, and any traumatic event leading to pTKA failure. Potentially avoidable indications included atraumatic instability, intraoperative fracture, metal allergy, and atraumatic patellar instability or maltracking. Aseptic loosening was considered avoidable if it occurred in the presence of component malpositioning or poor cementation technique. RESULTS:There were 112 (67.1%) unavoidable cases and 55 avoidable cases (32.9%). Of the unavoidable cases, there were 68 rTKA for infection or wound complications (60.7%), 23 for arthrofibrosis (20.5%), 6 for instability (5.4%), 6 for postoperative fracture (5.4%), 6 for aseptic loosening (5.4%), and 3 for extensor mechanism pathology following trauma (2.6%). Of the potentially avoidable rTKA, 24 were for aseptic loosening (43.7%), 23 for atraumatic instability (41.8%), 6 for atraumatic extensor mechanism pathology (10.9%), 1 for nickel allergy (1.8%), and 1 for intraoperative fracture (1.8%). CONCLUSION/CONCLUSIONS:These findings indicate that over 30% of early rTKA are potentially avoidable. Interventions should focus on addressing potentially avoidable causes such as short-term aseptic loosening and instability to reduce the need for costly and resource-intensive rTKA. Level of evidence III, retrospective observational analysis.

INTRODUCTION/BACKGROUND:The purpose of this study was to identify common complications and the rates of readmission and revision in total knee arthroplasty (TKA) patients younger than 65 years. METHODS:Using the American Joint Replacement Registry, we conducted a retrospective review of all TKAs done in patients aged 18 to 65 years from 2012 to 2020. Demographic factors such as age, sex, Charlson Comorbidity Index (CCI), and preoperative Veterans RAND 12-Item Health Survey Physical Component Summary (VR-12 PCS) scores were collected. We excluded patients older than 65 years and revision, oncologic, and nonelective cases. Primary outcomes included cumulative revision rate, 90-day readmission rate, and reason for revision. Univariate analysis and the Kaplan-Meier method were used. RESULTS:Six thousand one hundred seventy-nine patients were included. The average age was 58.8 years (SD 5.5 years), 61% were female, 82% were White, and 88% had a CCI of 0 (1 = 8% and ≥2 = 4%). The mean follow-up was 42.51 months. Seventy-four patients (1.2%) underwent revision. Sixty-nine patients (1.1%) were readmitted within 90 days. No factors assessed increased revision rates. Revision-free survivorship was 98.7% (95% CI 98.4 to 99.0) and 98.6% (95% CI 98.2 to 99.0) at 5 and 8 years, respectively. Infection (15%), aseptic loosening (14%), and instability (12%) were the most common indications for revision. CONCLUSION/CONCLUSIONS:TKA done in young and presumed active patients has excellent survivorship. Long-term follow-up is needed to assess survival trends in this growing population.

Patients undergoing total joint arthroplasty (TJA) with multiple comorbidities require medical clearance recommendations from their primary care provider, which if not adhered to can lead to adverse postoperative complications. In this quality improvement initiative, we explore the impact of a standardized handoff process incorporating medical clearance postoperative recommendations and orthopaedic-specific context on information transfer in TJA. A systematic review of quantitative and qualitative studies from 2014 to 2019 was completed to draw a conclusion about the best practice methods for the development of a standardized handoff process. Prior to implementation, evidence was reviewed to inform activities such as baseline chart audits, attainment of stakeholder input regarding handoff, exploration of wound closure equipment utilization, and standardization of a structured "smart phase" that incorporates medical clearance recommendations and orthopaedic-specific context information. After provider education was completed and the new handoff approach initiated, data were collected to compare postintervention outcomes such as transfer of information and wound kit distribution cost analysis. At baseline, 42% of patients had medical clearance postoperative recommendations handed off when they were provided. At completion, the new handoff smart phrase was used 97% for the first handoff and 100% for the second handoff. Medical clearance postoperative recommendations were captured in the electronic health record 83% of the time when they were provided. When the new smart phrases were utilized, wound closure, precautions, and postoperative void status were always handed off. Once wound closure technique was specified, bedside nurses were able to provide the appropriate wound closure removal equipment at discharge, projecting cost savings of $0.69 per case (∼234 cases per month). The use of a standardized handoff smart phrase that includes specialty specific context and postoperative medical management requirements successfully improved the information transfer between providers in a large academic orthopaedic medical center.

Background:Dual mobility (DM) bearings for total hip arthroplasty (THA) have been proposed to reduce the risk of instability in high-risk patients; however, their utility in primary THA remains relatively unexplored. No previous reports have described whether surgical approach influences outcomes associated with DM implant systems. This study aims to compare patient reported outcomes and post-operative groin pain between patients undergoing anterior approach versus posterior approach following primary THA with DM implants. Methods:We retrospectively reviewed all patients who underwent primary THA and received a DM implant between 2011-2021. Patients were stratified into two cohorts based on surgical approach (anterior vs. posterior approach). Primary outcomes included the presence of substantial postoperative groin pain as well as readmission and revision rates. Demographic differences were assessed using chi-square and independent sample t-tests. Outcomes were compared using multilinear and logistic regressions. Results:Of the 495 patients identified, 55 (11%) underwent THA via the anterior approach and 440 (89%) via the posterior approach. Surgical time (100.24 vs. 109.42 minutes, p=0.070), length of stay (2.19vs.2.67 days,p=0.072), discharge disposition (p=0.151), and significant postoperative groin pain (1.8%vs.0.7%,p=0.966) did not statistically differ between the cohorts. 90-day readmission (9.1%vs.7.7%,p=0.823) and revision rate (0.0%vs.3.0%,p=0.993) did not significantly differ as well. Specifically, readmission (p=0.993) and revision (p=0.998) for instability did not significantly differ between the cohorts. We found no statistical difference in HOOS, JR (p=0.425), VR-12 PCS (p=0.718), and VR-12 MCS (p=0.257) delta score improvement from preoperative to 1-year follow-up between the two groups. Conclusion:.

The study aimed to optimize value-based health care practices in total joint arthroplasty (TJA), and we need to understand how the surgical setting can influence efficiency of care. While this has previously been investigated, the purpose of this study was to clarify if these findings are generalizable to an institution with an orthopaedic specialty hospital. A retrospective review was conducted of 6,913 patients who underwent primary or revision total knee arthroplasty (TKA) at one of four hospitals within a single, urban, and academic health system: a high volume academic (HVA) hospital, a low volume academic (LVA) hospital, a high volume community (HVC) hospital, or a low volume community (LVC) hospital. Patient demographics were collected in an arthroplasty database, as were operating room (OR) times and several specific time points during the surgery. The HVA (orthopaedic specialty) hospital had the shortest total primary TKA OR times and the LVC that had the longest times (156.69 vs. 174.68, p < 0.0001). The HVA hospital had the shortest total revision TKA OR times, and the LVC had the longest times (158.20 vs. 184.95, p < 0.0001). In our health system, the HVA orthoapedic specialty hospital had the shortest overall OR time, even when compared with the HVC hospital. This is in contradistinction to prior findings that HVC institutions had the shortest OR times in a health system that did not have an orthopaedic specialty hospital. This provides evidence that an orthopaedic specialty hospital can be a model for efficient care, even at an academic teaching institution.

AIMS/OBJECTIVE:Navigation devices are designed to improve a surgeon's accuracy in positioning the acetabular and femoral components in total hip arthroplasty (THA). The purpose of this study was to both evaluate the accuracy of an optical computer-assisted surgery (CAS) navigation system and determine whether preoperative spinopelvic mobility (categorized as hypermobile, normal, or stiff) increased the risk of acetabular component placement error. METHODS:< 10°) spinopelvic mobility contributed to increased error rates. RESULTS:The paired absolute difference between CAS and postoperative imaging measurements was 2.3° (standard deviation (SD) 2.6°) for inclination and 3.1° (SD 4.2°) for anteversion. Using a target zone of 40° (± 10°) (inclination) and 20° (± 10°) (anteversion), postoperative standing radiographs measured 96% of acetabular components within the target zone for both inclination and anteversion. Multiple logistic regression analysis controlling for BMI and sex revealed that hypermobile spinopelvic mobility significantly increased error rates for anteversion (odds ratio (OR) 2.48, p = 0.009) and inclination (OR 2.44, p = 0.016), whereas stiff spinopelvic mobility increased error rates for anteversion (OR 1.97, p = 0.028). There were no dislocations at a minimum three-year follow-up. CONCLUSION/CONCLUSIONS: 2022;3(6):475-484.

INTRODUCTION/BACKGROUND:Traditionally, most efforts have focused on readmission rates while little has been reported on emergency department (ED) presentation. This study aims to analyze the difference between same-day discharge (SDD) and non-SDD primary total hip and knee arthroplasty (THA and TKA) cases to determine the rate and reasons associated with 90-day ED presentations. METHODS:We retrospectively reviewed all patients who underwent primary THA and TKA between 2011-2021. The patients were separated into two cohorts: 1.)SDD;2.)required a longer length-of-stay(LOS). The primary outcome was an ED visit within 90-days of the index operation. Secondary outcomes included reasons for ED visits and readmission rates. Multivariable logistic regressions were performed to compare the two groups while accounting for significant demographic variables. RESULTS:Of the 24,933 patients included, 1,725(7%) were SDD and 23,208(93%) required a longer LOS. The overall rate of 90-day ED visits was significantly lower for patients who were SDD compared to non-SDD (1.6%vs.4.0%,p=0.004). However, when stratified based on the reason for ED visit, no single cause was significant between the two cohorts. The most commonly reported reasons were pain (32.1%vs.26.7%,p=0.064) and other non-orthopedic related medical issues (25.0%vs.29.5%,p=0.206). Among those who presented to the ED, the readmission rate did not statistically differ (25.0%vs.23.4%,p=0.131). CONCLUSION/CONCLUSIONS:Patients that underwent SDD were less likely to present to the ED within 90-days following their surgery compared to non-SDD. Approximately three-fourths of the patients in both cohorts that visited the ED did not require readmission. Future efforts should focus on developing interventions to reduce the burden of these visits on the healthcare system.

INTRODUCTION/BACKGROUND:Airborne biologic particles (ABPs) can be measured intraoperatively to evaluate operating room (OR) sterility. Particulate matter (PM) up to 2.5 microns can contain microbial species which may increase infection risk. Our study examines differences in air quality and ABP count in primary (pTKA) and revision total knee arthroplasty (rTKA). METHODS:We analyzed primary and revision TKAs in a single operating room at an academic institution from January 2020 to December 2020. Procedures from March 15, 2020-May 4, 2020 were excluded to avoid COVID-related confounding. Temperature, humidity, and ABP count per minute were recorded with a particle counter intraoperatively and cross-referenced with surgical data from the electronic health records (EHR) using procedure start and end times. Descriptive statistics were used to evaluate differences in variables. P-values were calculated using t-test and chi-square. RESULTS:A total of 107 TKA cases were included: 79(73.8%) pTKAs and 28(26.2%) rTKAs. Time spent in room was significantly higher for rTKAs (primary: 176+46.7 minutes vs. revision: 220+47.1,p<0.0001). Compared to pTKAs, rTKAs had significant percent increases in ABP rates for particles measuring 0.3um(+70.4%,p<0.001), 0.5um(+97.2%,p<0.0001), 1.0um(+53.2%,p=0.001), 2.5um(+30.3%,p=0.017), and for PM 2.5(+108.3%,p<0.001) and PM5.0(+105.6%,p<0.001). CONCLUSION/CONCLUSIONS:RTKAs had significantly longer time spent in room and significant percent increases in ABP rates for particles measuring 0.3um, 0.5um, and 1.0um compared to pTKAs. Measurements of PM2.5 and PM5.0 (which can contain large numbers of microbes) were also significantly greater in rTKAs. Further research is needed to determine whether the size and quantity of ABPs translates to higher infection rates following rTKA.

Purpose/UNASSIGNED:Computer navigation in total hip arthroplasty (THA) offers potential for more accurate placement of acetabular components, avoiding impingement, edge loading, and dislocation, all of which can necessitate revision THA (rTHA). Therefore, the use of computer navigation may be particularly beneficial in patients undergoing rTHA. The purpose of this study was to determine if the use of computer-assisted hip navigation reduces the rate of dislocation in patients undergoing rTHA. Methods/UNASSIGNED:A retrospective review of 72 patients undergoing computer-navigated rTHA between February 2016 and May 2017 was performed. Demographics, indications for revision, type of procedure performed, and incidence of postoperative dislocation were collected for all patients. Clinical follow-up was recorded at 3 months, 1 year and 2 years. Results/UNASSIGNED: < 0.05). Conclusion/UNASSIGNED:Our study demonstrates a significant reduction in dislocation rate following rTHA with computer navigation. Although the cause of postoperative dislocation is often multifactorial, the use of computer navigation may help to curtail femoral and acetabular malalignment in rTHA. Level of Evidence/UNASSIGNED:Level III: retrospective.

Purpose/UNASSIGNED:Use of dual mobility (DM) articulations can reduce the risk of instability in both primary and revision total hip arthroplasty (THA). Knowledge regarding the impact of this design on patient-reported outcome measures (PROMs) is limited. This study aims to compare clinical outcomes between DM and fixed bearing (FB) prostheses following primary THA. Materials and Methods/UNASSIGNED:All patients who underwent primary THA between 2011-2021 were reviewed retrospectively. Patients were separated into three cohorts: FB vs monoblock-D vs modular-DM. An evaluation of PROMs including HOOS, JR, and FJS-12, as well as discharge-disposition, 90-day readmissions, and revisions rates was performed. Propensity-score matching was performed to limit significant demographic differences, while ANOVA and chi-squared test were used for comparison of outcomes. Results/UNASSIGNED:=0.608) between the groups. Conclusion/UNASSIGNED:DM bearings yield PROMs similar to those of FB implants in patients undergoing primary THA. Although DM implants are utilized more often in patients at higher-risk for instability, we suggest that similar patient satisfaction may be attained while achieving similar dislocation rates.